Download:
pdf |
pdf
OMB # 0925‐XXXX
Expiration Date: XX/XXXX
IDEAL-Screening for Eligibility
Level 1-Telephone Interview
STATEMENT OF CONFIDENTIALITY
Collection of this information is authorized by Public Law 93-296. Rights of study participants are protected
by The Privacy Act of 1974. Participation is voluntary, and there are no penalties for participating or
withdrawing from the study at any time. Refusal to participate will not affect your benefits in any way. The
information collected in this study will be held in professional confidence. Names and other identifiers will
be separated from information provided and will not appear in any report of the study. Information provided
will be combined for all study participants and reported as statistical summaries.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN
Public reporting burden for this collection of information is estimated to average 10 minutes per response,
including the time for reviewing instructions, searching exiting data sources, gathering and maintaining the
data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing burden to: NIH, Project Clearance Branch,
6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974 ATTN:PRA (0925-xxxx). Do not return the
completed form to this address.
IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R -
/ 2 0
First name:
Last name:
INTRODUCTION: "The following questions cover basic demographic information."
1.
ASK OR CONFIRM: are you [male/female]?
Male
2.
Female
Don't know
Refused
/
What is your date of birth?
Month
3.
How old are you today?
4.
What is your current marital status?
5.
/ 1 9
Day
Year
Years
Married
Separated
Widowed
Don't know
Living with a partner
Divorced
Never married
Refused
Is English your first language?
Yes
No
Don't know
Refused
If 'Yes,' go to question 7.
6.
Are you fluent in English?
Yes
7.
No
Don't know
Are you of Spanish, Hispanic, or Latino origin?
Yes, of Hispanic origin
8.
Refused
No, not of Hispanic origin
Don't know
Refused
What race do you consider yourself to be?
White
American Indian or Alaskan Native
Black or African American
Don't know
Asian or Pacific Islander
Refused
2578
1
IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R 9.
What is the highest grade in school that you completed?
/ 2 0
Years of school
Examiner Note: use 00 for no formal schooling, 12 for high school (or
GED equivalent), 14 for two year college / Associate's degree, 16 for
four year college, 18 for Master's degree, 19 for Law degree, 20 for
MD or PhD, 21 for multiple graduate degrees, 77 for refused and 88
for unknown).
INTRODUCTION: "The next several questions concern how well (you) function in
(your) usual environment, without the use of special equipment or help from another
person."
10. Because of a health or physical problem, do you have any difficulty walking a quarter
of a mile, that is about 2 or 3 blocks, without stopping?
Yes
No
11. Do you need to use a cane, a walker, or a wheelchair?
Yes
No
Don't know
Refused
12. Because of a health or physical problem, do you have any difficulty walking up 10
steps, that is about 1 flight, without resting?
Yes
No
13. Because of a health or physical problem, do you have any difficulty lifting or carrying
something weighing 10 pounds, for example a small bag of groceries or an infant?
Yes
No
14. Because of a health or physical problem, do you have any difficulty getting in and out
of bed or chairs?
Yes
No
Don't know
Refused
15. Because of a health or physical problem, do you have any difficulty bathing or
showering?
Yes
No
Don't know
Refused
16. Because of a health or physical problem, do you have any difficulty dressing?
Yes
No
Don't know
Refused
2578
2
IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R -
/ 2 0
17. Because of a health or physical problem, do you have any difficulty using the toilet,
including getting to the toilet?
Yes
No
Don't know
Refused
INTRODUCTION: "Now I would like to ask you some questions about your eyesight
and hearing."
18. Can you see well enough to read an ordinary print newspaper (with glasses or
contacts, if you wear them)?
Yes
No
Don't know
Refused
19. Can you hear well enough to maintain a conversation in a crowded place such as a
restaurant or train station (wearing a hearing aid, if used)?
Yes
No
Don't know
Refused
lbs.
20. What is your weight?
Don't Know
Refused
INTRODUCTION: "The following questions concern your past medical and
health-related history as well as diagnoses and treatments received."
21. Has a doctor or other health professional ever said you had a heart attack or
myocardial infarction?
Yes
No
Don't know
Refused
22. Has a doctor or other health professional ever said you had heart failure or congestive
heart failure?
Yes
No
Don't know
Refused
23. Has a doctor or other health professional ever said you had angina (pectoris), chest
pain due to heart disease or coronary artery disease?
Yes
No
Don't know
Refused
24. Has a doctor or other health professional ever said you had a stroke?
Yes
No
Don't know
Refused
2578
3
IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R -
/ 2 0
25. Has a doctor or other health professional ever said you had high blood pressure or
hypertension?
Yes
No
If 'No,' go to question 26.
25a. Do you know your average blood pressure?
Yes
No
Don't know
Refused
25b. What is your average blood pressure?
Systolic
Diastolic
26. Do you have diabetes?
Yes
No
Don't know
Refused
27. In the last two years, have you had symptoms of or have you been treated for asthma,
chronic bronchitis or emphysema?
Yes
No
Don't know
Refused
28. Has a doctor or other health professional ever said you had cirrhosis or liver disease?
Yes
No
Don't know
Refused
29. Has a doctor or other health professional ever said you had HIV or AIDS?
Yes
No
Don't know
Refused
30. Have you leaked urine (even a small amount) more than three times in the last month?
Yes
No
Don't know
Refused
2578
4
IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R -
/ 2 0
31. During the last 3 months, did you leak urine:
(Check all that apply)
When you were performing some physical activity, such as coughing, sneezing, lifting,
or exercising?
When you had the urge or the feeling that you needed to empty your bladder, but you
could not get to the toilet fast enough?
Without physical activity and without sense of urgency
32. Have you ever had any of the following procedures: bypass surgery or (balloon)
angioplasty on your coronary (heart), arteries, or aortic aneurysm repair?
Yes
No
Don't know
Refused
33. Has a doctor or other health professional ever said you had cancer, a malignant
growth, or malignant tumor? (Examiner note: Exclude uterine "fibroids")
Yes
No
q
33a. Was it a cancer of the skin?
Yes
No
If 'No,' go to question 33c.
33b. Was it a melanoma?
Yes
No
If 'No,' go to question 34.
33c. Has there been any activity or recurrence
(of any cancers) in the last 10 years?
Yes
No
2578
5
IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R -
/ 2 0
34. Have you had any joint replacement surgery?
Yes
No
Don't know
Refused
35. Has a doctor (or other health professional) ever said you had a connective tissue
disease, such as rheumatoid arthritis, gout, lupus, ulcerative colitis, Crohn's disease, or
scleroderma?
Yes
No
Don't know
Refused
36. Has a doctor (or other health professional) ever said you had Parkinson's disease,
multiple sclerosis, or ASL (Lou Gehrig's disease)?"
Yes
No
Don't know
Refused
37. Have you had a seizure in the last 10 years or are you currently receiving chronic
treatment for seizures?"
Yes
No
Don't know
Refused
38. Has a doctor or other health professional ever said you have any psychological or
psychiatric conditions like manic depressive disorder or bipolar disorder, obsessive
compulsive disorder, or schizophrenia?
Yes
No
Don't know
Refused
39. Do you regularly take any medication for pain?
Yes
No
If 'No,' go to question 41.
40. Have you been taking this medication regularly for at least a month?
Yes
No
Don't know
Refused
41. Do you regularly take any other medications?
Yes
No
If 'Yes,' complete Medication List.
2578
6
IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R -
/ 2 0
IDEAL MEDICATIONS LIST
Interviewer Instructions: As per questionnaire item 41, please record all
medications taken by the respondent (other than pain medications) in the following
table. Include the name of the medication and length of time used.
Example:
Medication Name
Length of time used
Lasix
4 mo
2578
7
IDEAL
Screening for Eligibility
Level 1
Telephone Interview
Screening Protocol ID:
Tester ID:
Date Completed:
/
S C R -
/ 2 0
ADDITIONAL INFORMATION
INTRODUCTION: "Now I would like to ask you some general questions."
42. How did you find out about the IDEAL Study?
43. Please tell me why you became interested in joining the study?
44. Are you aware that your participation in the BLSA Study as an IDEAL participant is for
the rest of your life unless otherwise incapacitated?
Yes
No
Don't know
Refused
45. If you become unable to come into the unit for participation in the study, are you
willing to have a home visit?
Yes
No
Don't know
Refused
46. If you are not eligible for this study, are you willing to learn about additional studies?
Yes
No
Don't know
Refused
2578
8
| File Type | application/pdf |
| Author | legum_g |
| File Modified | 2010-11-18 |
| File Created | 2010-10-12 |